pacientes 3

I may have had my first Ecuadorian patient with TB last week.  She was a 74-year-old woman with a 6-month history of edema (swelling) in her legs that had worsened over the past week with associated shortness of breath.  It sounded like a classic picture of heart failure.  Her lungs sounded surprisingly clear, however, and she didn't have the cardiomegaly (enlarged heart) on X-ray or distended neck veins typical of congestive heart failure, although she did have impressive edema to her hips.  What she did have on the X-ray, however, fit more with her history of oral candidiasis with some odynophagia (pain with swallowing) and progressive weight loss:  a circular lesion with an air-fluid level suspicious for active tuberculosis (TB).  I sent her for AFB smears, as Ecuador requires two, and an HIV test, although she isn't coughing up blood and doesn't have night sweats (which with weight loss are the classic triad of TB), so I'm not completely sure of the diagnosis.  She sure has something going on in that left lung, though (see below).

 

This past week we admitted what is I think our third or fourth patient with snake bite in my time here.  This poor fellow had been treated in a different hospital a month ago, and the management had been suboptimal (especially not receiving antiofídico, antivenom, when he should have).  He had gone to a second hospital but left against medical advice when they recommended amputation of his right leg below the knee.  He went home and his wife put herbal dressings on his leg for the next three weeks until they decided to come here.  His entire anterior (front) leg was necrotic, and there is a 6-inch space between the skin on one side and on the other where there used to be muscle and skin.  Both leg bones are exposed, and on the X-ray below it looks like both have osteomyelitis.  He was resistant initially to the idea of amputation, but the surgeons have explained to him that it may end up being losing his leg or slowly losing his life from spreading infection.  He did have a below-the-knee amputation then towards the end of last week and seems to be doing fairly well.  Compare the moth-eaten appearance of his fibula (smaller bone) X-ray and the darkened out, infected marrow of his tibia (larger bone) with the normal image below.

I had another interesting patient in clinic this week, a 15 year old girl with 2-day history of epigastric and right upper quadrant pain, nausea, and vomiting.  Her exam had some mild epigastric tenderness and normal vital signs, and she said her vomiting was already getting somewhat better.  I figured it was a gastritis, probably from a viral infection, but they were worried about her having reflux, so I gave them a prescription for Tylenol and ranitidine and asked her to come back if she wasn't feeling better.  She came back three days later complaining of yellow eyes.  I did note some mild scleral icterus, although I had thought that was her normal pigmentation when seeing her at the first appointment, but she and her father agreed this was new, so I ordered blood tests for liver functions, including bilirubin (the cause of yellow coloring of eyes/skin).  To my surprise, she had not only mild hyperbilirubinemia (2.7) but also elevated transaminases (AST 200s, ALT 600s) and an elevated alkaline phosphatase (~AP 250).  I ordered an eco(sonografia) (ultrasound) and acute hepatitis panel.  She didn't come back for follow up today, so I don't know the answer (and I'm not sure how long hep A IgM takes here anyway), but it seems she may be my first patient with hepatitis A.  Either that, or she's the youngest patient I've seen with symptomatic gallstones!  Hepatitis A is usually self-limited and she is clinically already getting better, so she will probably be fine.